Pediatric Coding Alert

Avoiding modifiers because you don't know the rules could cause you to leave cash on the table. When it comes to appending CPT® modifiers to your codes, the rules can be daunting, and insurers' regulationsonly compound the confusion. But if you're up to speed on these key modifier billing practices, you'll be raking in deserved pay. Figure out how you would answer the following five questions submitted to Pediatric Coding Alert to determine whether you're missing any opportunities. Know When Modifier 26 Applies We commonly report radiology codes for services such as chest x-rays without a modifier when the pediatrician only performs the interpretation. In the past we have received appropriate reimbursement for only the professional component because the carrier paid the hospital that performed the x-ray for the technical component. Lately, however, we have received some full payments on these claims, even though we only deserve professional-component pay. What's going on? Question: It's possible that in the past, your payers didn't require a modifier on the claim, but perhaps they've recently conformed to CPT® coding conventions and now you'll have to append modifier 26 (Professional component) to your claim. Answer: If your physician provides an interpretation and report for an x-ray or other radiological service in the treatment of a patient, that's not always just part of his E/M--in some cases, you can separately bill for the interpretation and report by appending modifier 26 to the CPT® code. Background: Typically, the technologist that performed the patient's x-ray will bill the code--such as 71010 (Radiologic examination, chest; single view, frontal)--with modifier TC (Technical component) to indicate that he is billing for the equipment, room charge, film and radiologic technician, but not for the physician's interpretation. If the physician who renders the interpretation is with a separate professional group and is not a hospital employee, you should report the service with modifier 26 to obtain his proper share of the reimbursement. In order for a physician to be paid for an x-ray interpretation, he must provide and document only the interpretation for the study and must provide a written report similar to that which would be prepared by a specialist in the field. Remember: Some plans will only pay for an official radiologist's interpretation. In any case, they will only pay for one official interpretation of an x-ray, typically the first that is billed. Collect for Those Bilateral Procedures Question: Our physician removed 11 warts from both of a 14-year-old patient's hands. Should we report several units of the wart removal code, or use a bilateral modifier to tell the insurer that it was a bilateral procedure? If your insurer follows Medicare guidelines, you should check the Medicare Physician Fee Schedule's Column "T," which indicates whether bilateral services apply to each code. Answer: Because the Fee Schedule's bilateral status indicator for 17110 (Destruction [eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions) is "0," the 150 percent payment adjustment for bilateral procedures does not apply. Therefore, you should report 17110 just once. You don`t need to append a modifier such as 50 (Bilateral procedure) to either code.   Other procedures, such as forearm splint application (29125), list a "1" in column T, which means you can append modifier 50 or modifiers RT (Right side) and LT (Left side), depending on which combination your payer prefers. Therefore, if the physician applies forearm splints to both the left and right arms, you can either report 29125- LT (Application of short arm splint [forearm to hand]; static) and 29125-RT, or you can simply report 29125-50. Mine All Legitimate Modifier 59 Opportunities. Question: I know I've read before that a modifier can be used to separate CCI edits, but my office manager frowns on us using modifier 59 because she doesn't want us to be accused of overusing or misusing it. Should we use this modifier or not? Some coders assume that if the Correct Coding Initiative (CCI) forbids billing two codes on the same date, that's the end of the story. But in fact, you may be missing out on some legitimate cases where CCI allows you to usea modifier such as 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) or 59 (Distinct procedural service) to override an edit. Answer: Always scan the CCI edits to see whether a modifier can override your code pair edit. Of course, you should only a modifier when the services are separate, distinct, and medically necessary. Modifier 59 is a modifier of last resort. However, when it is appropriate and needed to unbundle an edit, use it. CCI edits bundle 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device) into inhalation treatment code 94640. CCI, however, allows you to report a modifier to override this bundle when circumstances make separately reporting the education appropriate. For Medicaid and payers that follow the edits, if the education occurs while the patient is receiving the inhalation treatment, do not separately bill the education. However, if, for example, the pediatrician provides the inhalation treatment and subsequently he or his nurse performs the training, you may report 94664 with modifier 59. Example: Are Separate Dx Codes Required to Use Modifier 25? Question: I recently heard that we do not need different diagnosis codes to use modifier 25 for reporting an E/M service on the same date as a procedure. But I've been told many times in the past by certified coders that when I bill a procedure with an E/M, I need to add modifier 25 to the E/M and point the primary diagnosis to the E/M and point a secondary diagnosis to the other procedure. Can you clear up my confusion? Proper modifier 25 use does not require a different diagnosis code. In fact, the presence of differentdiagnosis codes attached to the E/M and the procedure does not necessarily support a separately reportable E/M  service. Your key to separately reporting the E/M service lies in whether your doctor performed and documented separate and distinct evaluation and management work beyond what is considered to be part of the procedure. Answer: When using modifier 25, the diagnosis associated with the E/M service can be the same as the diagnosis associated with the same-day procedure, or the diagnosis associated with the E/M service can be different than the diagnosis associated with the sameday procedure. Whenever possible and appropriate, use a different ICD-9 for the E/M code. However, using the same diagnosis may be the accurate, correct option.The information about modifier 25 in the CPT® manual clearly indicates that you do not have  to have two different diagnosis codes to use the modifier. The CPT® manual description of modifier 25 states: "The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date." (Emphasis added) How it works: Go to the source: Both CPT® and Medicare rules (which many private payers follow) will allow the same diagnosis for the E/M service with modifier 25 and the procedure on the same day, and Medicare will reimburse for both with the same diagnosis, assuming both are reasonable and necessary and otherwise meeting Medicare coverage criteria. The catch is that the pediatrician's documentation should clearly establish that the E/M involved work over and above that typically associated with the procedure done at the same encounter and that the encounter's sole purpose was not to perform the procedure. If you receive denials on modifier claims simply because you use the same diagnosis code for the E/M and the procedure, you should appeal, assuming the documentation supports reporting the separate services. Appeal When You Feel You've Been Wronged. Is there any recourse if we know our insurer erroneously denied a claim when we are sure we've used our modifiers correctly? Question: Because many practices fear being labeled "troublemakers" or even worse yet, non-compliant with federal regulations, they accept payers at their word when a modifier isn't accepted or the claim is denied. If your payer denies your claim or requests a refund, research the issue before you take the payer's word for it. Answer: Most experts caution against rolling over with regard to alleged overpayments. If it is a clear overpayment, you must give the money back. However, if the claims were properly submitted and billed, you should appeal any time you feel your payer has wrongly denied your claim or incorrectly requested a refund.